Can cholelithiasis (gallstones) cause left upper quadrant pain in a patient with severe hypertension?

Can Cholelithiasis Cause Left Upper Quadrant Pain?

Cholelithiasis does not typically cause left upper quadrant (LUQ) pain—the classic presentation is right upper quadrant (RUQ) pain that may radiate to the right shoulder or supraclavicular region. 1, 2

Typical Pain Pattern in Cholelithiasis

• The characteristic presentation of cholelithiasis is RUQ abdominal pain, often elicited upon palpation with a positive Murphy's sign 2
• Pain typically occurs 30-60 minutes after meals and may radiate to the right supraclavicular region and/or right shoulder 2, 3
• Acute cholecystitis presents with RUQ pain, fever, and leukocytosis as the defining clinical triad 1

Why LUQ Pain is Atypical

• The gallbladder is anatomically located in the RUQ, making LUQ pain an unusual manifestation of biliary disease 1
• If a patient presents with LUQ pain, you should consider alternative diagnoses including splenic pathology, gastric disease, pancreatic tail pathology, splenic flexure colonic disease, or referred pain from other sources 4

Important Clinical Caveat for Severe Hypertension

• In patients with severe hypertension presenting with abdominal pain, consider pheochromocytoma as a rare but important differential diagnosis 5
• Pheochromocytoma can present with hypertensive crises and gastrointestinal complaints (including abdominal pain, nausea, vomiting) that may mimic or overlap with symptoms of cholelithiasis 5
• Physicians must consider pheochromocytomas in cases of drug-resistant hypertension or hypertensive crises, especially when associated with abdominal complaints 5

Recommended Diagnostic Approach

• If RUQ pain is present, ultrasound is the initial imaging test of choice with 90-95% sensitivity for detecting gallstones 3
• The American College of Radiology recommends RUQ ultrasound as the first-line imaging study (rated 9/9, usually appropriate) for suspected biliary disease 6, 7
• If LUQ pain is the primary complaint without RUQ involvement, investigate non-biliary causes first before attributing symptoms to cholelithiasis 4